Paying closer attention to patient information and educating (and re-educating) staff members are among the strategies for reducing billing errors and claim denials.

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s “friendly” Medicare chart auditors and system reviewers, our clinical team has observed significant errors in documentation and claims submission. Billing errors are caused by record inaccuracies as well as by systems and practices that are not compliant with regulatory guidelines. How can these errors be corrected, systems improved, and claim denials avoided?
       Correct billing starts with correct admission information. Information from the discharging facility must include the following: records verifying the 3-midnight qualifying stay; records verifying “look-back” information; a transfer sheet, which may include the initial physician certification; and the admission order to the skilled nursing facility (SNF).
       Accurate and timely certifications and re-certifications are among the leading aspects of noncompliance. The initial certification is required on admission or “as soon thereafter as is reasonable and practical.” But what does that mean, exactly? We know that we must meet all of the regulatory requirements that speak to certifications, so that it becomes clear when looking at initial certifications in light of all of the regulations. Section 1814 of the Social Security Act requires certifications and re-certifications. These regulations have not changed with the Prospective Payment System (PPS), except that language has been added that allows physicians (or other authorized practitioners) to verify that the beneficiary (eg, the patient, resident, or client) qualifies for a certain Resource Utilization Groups (RUG) score. Since few physicians understand the RUG criteria, this type of attestation rarely occurs, if ever.
       This certification process identifies the physician as having a major role in determining utilization of health care services. The physician is attesting to the fact that the client requires skilled nursing or skilled rehabilitation services on a daily basis and that such services can only be provided in an SNF on an inpatient basis. The physician is also certifying that the care is needed for a condition for which the client received inpatient hospital care.
       Certifications and re-certifications may only be signed and dated by physicians, nurse practitioners, and certified nurse specialists. [Note: These nurses may not be employed by the facility or have a service agreement through their employer to perform general nursing services for the facility.] Physician’s assistants, by regulation, may not certify or re-certify.

Requirements for Re-Certification

       Re-certifications must meet several criteria. First, they must contain the reasons for the continued need for post-hospital SNF care. Second, they must estimate the amount of time the client will need to remain at this level of care. Third, they must address plans for home care needs, if any. Finally (if appropriate), the re-certification may need to note that continued services are for a condition that arose after admission to the SNF while the client was still under treatment for the condition for which the client received hospital care. The narrative portion of this document cannot be generated after the physician has signed the re-certification. The authorizing practitioner must always date his or her signature.
       There are also requirements for timeliness of the re-certifications. They must be obtained on or before the 14th day of the SNF stay and at least every 30 days following the date that the physician signed the first re-certification.
       A specific “cert/re-cert” form is not required, but most professionals agree that a “standard” form assists the facility in tracking the certifications. The left sides of most of these forms contain prompts that assist the physician in completing the form within the correct timelines. These prompts should be completed on a case-by-case basis, and they should not say “on or before day 14, 44, or 74.” The regulations allow for an initial certification and re-certification to occur at the same time. If this happens on day 1 of the SNF stay, the next re-certification will be due on or before day 30. A well-worded physician progress note, office visit note, or treatment order occurring within the correct timeframes and meeting all content requirements could be used for a re-certification. However, tracking multiple formats in many locations makes this system impractical, if not impossible.

Minding the Minimum Data Set

       Another significant area of concern is the Minimum Data Set (MDS). The nurse and other staff who assist in the assessment and completion of the MDS must realize that their assessment data drives the RUG score and, therefore, the Medicare payment. An accurate MDS is essential. Time must be taken to review look-back information from the hospital stay. All diagnoses must be taken into consideration, and correct activities of daily living (ADL) information must be recorded. The PPS regulations call for the nurse assessor to select the Assessment Reference Date (ARD). This nurse must understand the PPS and the significance of the ARD as it relates to payment. The nurse assessor must also understand the requirements and payment implications pertaining to Significant Change in Status Assessments (SCSA) and Other Medicare Required Assessments (OMRA). The Resident Assessment Instrument (RAI) manual should be available, open to chapter 3, and referred to in preparing each MDS. Nurses cannot memorize all of the guidelines, but each time they refer to the manual is an enlightening experience. Subsequently, each MDS becomes more accurate.
       The registered nurse (RN) must not sign the MDS as complete until all assessors have completed their portions and signed off at the AA9 attestation. There can be no back-dating of assessments. The MDS nurse must have a manageable workload and time management skills to ensure he or she is performing the tasks within the regulatory requirement. He or she must also realize that RN licensure requires that all work be authentically dated.
       Documentation that can corroborate skilled need is crucial. The skilled nursing documentation is required at least once every 24 hours. The entry must speak to issues that support the reasons why the client was admitted to the SNF for post-hospital care. The documentation must relate to the reasons for which the client received hospital care. If the client had a knee replacement in the hospital, it is inadequate to document only blood pressure checks. An assessment of issues pertaining to the knee (eg, mobility, pain, surgical site, etc.) must be recorded. If therapy is part of the post-hospital SNF care, therapists must speak professionally to the therapy treatments and the client’s performance. A professional assessment of the participation and progress of the client must be made. Noting the specific repetitions of an activity is insufficient.
       When it is time to submit Medicare claims, the person signing the Uniform Billing Form 92 (UB-92) attests to the fact that the certifications and re-certifications have been obtained and are on file. (Refer to the form excerpt). Billers may be held personally responsible for incorrect billing. Claims cannot be submitted unless certifications are on file. The regulatory language says that certifications must be obtained at admission or as soon thereafter as is reasonable and practical. Since certifications/re-certifications must be in place prior to billing, we know that “as soon thereafter as is reasonable and practical” means that they must be obtained prior to billing, at least.
       Delayed certifications and re-certifications are acceptable in rare instances when the certifying documents have not been obtained within the regulatory time frames. These “special” certifications must, in addition to all other required language, stipulate the reason for the delay. Examples used in the regulation include a client who was unaware that he or she had a Medicare benefit and whose certification was not obtained at admission. Delayed certifications and re-certifications may not be generated after billing and back-dated to complete the paperwork or to submit with requested review documentation.
       Recommendations for an accurate Medicare PPS System in the SNF setting include:
1. Have a designated facility admissions coordinator (and one trained back-up person). This is not necessarily another full-time employee, but rather a knowledgeable staff person who is assigned this task.
2. Educate and re-educate admission staff and nursing management staff with regard to presumption of coverage regulations, administrative nursing criteria, and required admission information.
3. Design a facility system that ensures that certifications and re-certifications are completed accurately. Have one person (with a trained back-up person) assigned to this task. A medical records staff person is ideal.
4. Establish medical records audits around critical information issues. Often, medical records staff members are busy doing audits and tasks that are not needed or are not done at times that assist the facility’s compliance program. Having an audit within 72 hours of admission that looks for admission orders, certifications, and look-back information can be invaluable to the facility.
5. Educate and re-educate the MDS nurse(s). Insist that chapter 3 of the RAI manual be used as a side-by-side guide as the MDS is completed.
6. Have periodic audits by an outside professional to ensure MDS, documentation, and billing accuracy as well as appropriate reimbursement. Occasional objective oversight is needed to assure management that it is not at risk for denials and that it is receiving the correct payment for the Medicare services rendered.
7. Have the PPS run by facility personnel. The nurse assessor should choose the ARD. A contracted rehabilitation company is not, by regulation, the appropriate entity to manage the facility program. Staff therapists are, indeed, part of the Medicare service team; therapists do not, however, have the authority to decide when a client should be discontinued from skilled services. Therapists, in conjunction with physician’s orders, do assist in the decision to discontinue therapy services. Remember, vendor therapy companies may have their own payment interests in mind when determining ARDs and deciding when to provide therapy services.
8. Educate and re-educate all contributors to the MDS.
9. Have a facility system that ensures that the billing person can attest to the presence of certifications and re-certifications prior to billing.
10. Have a facility nurse manager, usually the Director of Nursing (DON), establish relationships with the medical director and other physicians to ensure adequate and accurate physician documentation and participation in the Medicare service delivery.
11. If you are not sure that your PPS is adequate and accurate, do not be afraid to ask for help.