MDS Alert

Published on Tue Mar 30, 2004 PDF

4 action items to help you prevent technical denials.

What could be more disheartening than working hard to provide great care that the SNF ends up holding the bag for?
 
That's exactly what will happen if your facility doesn't follow Medicare's rules for certifying and recertifying a resident's need for a skilled level of care at admission, on or before day 14 and every 30 days thereafter until the resident's 100-day benefit period is up or before.

Never fear: You can keep those certs/recerts flowing and your SNF's Medicare PPS payment on track with the following key strategies.

1. Develop a surefire system to secure the initial physician certification at admission or shortly thereafter. "It's best to get the certification documentation at admission or at the latest by 72 hours post admission," says Cindy MacQuarrie, MN, RN, a consultant with BKD Inc. in Springfield, MO. MacQuarrie has seen facilities that don't get the physician's signature until after the resident's discharge, which is a surefire ticket to a technical denial upon medical review.

Strategies for success: "The facility can include the physician certification form as part of the admission order form," MacQuarrie suggests. Or you can fax the certification form to the physician and have him/her fax it back. "Then the physician signs off on the faxed signature when he/she comes in to see the resident -- just as he/she does for telephone orders," notes Betsy Anderson, a consultant with FR&R Healthcare Consulting in Deerfield, IL.

2. Track when the recerts are due. Your facility also needs tracking systems to obtain recerts on time. For example, Transmittal 372 (March 2002) clarifies that SNFs may get the physician to provide the initial certification and one more recertification at the same time. But that puts the facility on a different cycle for obtaining recerts than the typical 14 days, 44 days and 74 days. "Counting admission as day one, the SNF has 30 days from the date of the first recertification to obtain the next one," says Marilyn Mines, RN, also with FR&R Healthcare Consulting. So if the physician signs off on that first 14 day recert on day four, then the SNF has 30 days from that date to get the next certification, which would be day 34.

The same is true if the facility obtains subsequent recertifications early. The next recert will be due no later than 30 days after the date of signing, says Jennifer Gross, RN, a consultant with LTCQ Inc. in Lexington, MA.

That's not a problem, however, if the facility tracks the time that recerts are due for each resident. If not, the SNF will have recerts slipping through the cracks right and left. For that reason, "some facilities find it easier to stay on the same cycle for all residents," Anderson notes.

3. Give yourself enough time to get the recerts. If you don't obtain the first recert at the same time as the initial recertification, make sure to get the ball rolling well before the fourteenth day of the resident's SNF stay when it's due. "Start sending the recert form (by mail or fax) or asking the physician to sign it on about the seventh day of the resident's stay if it looks like the resident will be in the facility on the 14th day and thereafter," MacQuarrie advises.

4. Include the required language and information. Medicare doesn't require a specific form to certify/recertify skilled services. "FIs should accept signed certification or recertification statements even if they are included on forms, notes or other paperwork in the resident's medical record," says Cheryl Field, MSN, RN, CRRN, director of clinical and reimbursement services for LTCQ Inc. in Lexington, MA.

Although Medicare doesn't require a specific form, the cert/recert must include specific language and information if it's going to fly with the FI. "The certification requires that the physician clearly indicate post hospital extended services are required based on the need for a daily skilled nursing or rehab services related to a condition treated in the hospital stay," Anderson advises. "A resident can, however, be admitted to the SNF for a condition that arose from the condition the person was treated for in the hospital," says Jan Zacny, RN, a consultant with BKD Inc.
 
Example: Say a resident had pneumonia treated in the hospital where he developed a Stage 3 pressure ulcer due to being ill and immobile. In that case, the nursing facility would list both of those conditions as the reasons for skilled nursing care. What if the patient's pneumonia resolved in the hospital but he still had the Stage 3 pressure ulcer upon admission to the SNF? Skill him/her based on the wound, Zacny advises. The only instance Zacny can think of where someone might not qualify for skilled care within 30 days post-hospitalization would be to treat a new condition, such as diabetes, diagnosed after discharge from the hospital. Documentation tip: Make sure the word "certify" appears somewhere in the certification verbiage, MacQuarrie advises.

For recertification purposes, the facility can count a condition that arose while the person was in the SNF -- for example, a wound infection, explains Zacny. A valid recertification should include adequate written records of the reasons for continued extended care services, the estimated period of time the patient will remain in the facility, and any plans for home care. Anderson's interpretation of the latter requirement is to "provide as much detail as possible from a discharge planning perspective." Try this: Record the RUG level on the certification form and then spell out what it is (i.e., why the resident qualified for it due to rehabilitation services or a clinical condition /requirements), Zacny advises.
 
Practical tip: If the physician documents the required information in the progress notes, copy that and attach it to the cert form in the file, Anderson suggests. Transmittal 372 notes, in fact, that "if all the required information [for certification] is in the progress notes, the physician's statement could indicate that the individual medical records contain the required information and that continued posthospital extended care services are medically necessary."

Better Late Than Never

Transmittal 372 says the FI should "honor" delayed certs and recerts that occur due to an oversight or lapse. But the SNF has to provide a rationale to support the fact that the physician deemed the resident skilled in a timely fashion, even though he/she didn't document it, Field advises. "The transmittal gives the facility discretion to determine the format for delayed certification, such as a letter from the physician with all the certification content requirements and an explanation for the delay in compliance," she adds. One facility, for example, had the physician write letters for several residents when their original certifications were shredded in error.