Last Modified: 9/15/2023
Business: Part A
First Coast is receiving appeals for denials of services in which the inpatient skilled nursing facility (SNF) services documentation is lacking required information to allow payment of the claim at the first and second level of appeals.
1. The certification or recertification is not obtained at the time of admission or as soon thereafter as is reasonable and practicable.
2. Actual therapy minutes documented in the treatment record did not equal the minutes reported on the minimum data set (MDS) for physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) services.
3. Medical records did not support the medical necessity of the SNF services provided.
Certification and recertifications:
• The first recertification must be made no later than the 14th day of post-hospital inpatient extended care.
• Subsequent recertifications must be made at intervals not exceeding 30 days.
• Delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence relevant for purposes of explaining the delay.
• Certifications should reflect that the beneficiary needed daily skilled care that could only be provided in a SNF setting.
Therapy minutes documented in the treatment record must match the minutes reported on the MDS for PT, OT, or SLP services.
Claims for SNF services need to include enough documentation to enable a clinical reviewer to determine that:
• The beneficiary requires skilled involvement for the services in question to be furnished safely and effectively.
• The services themselves are reasonable and necessary for the treatment of a resident’s illness or injury. For example, the services must be consistent with:
• The nature and severity of the individual’s illness or injury
• The individual’s particular medical needs, and accepted standards of medical practice
The documentation must be accurate and avoid vague or subjective descriptions of the beneficiary’s care. The documentation must also show that the services are appropriate in terms of duration and quality and promote the documented therapeutic goals. The beneficiary goals must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage.
A beneficiary’s medical record must include:
• History and physical exam pertinent to the resident’s care (including the response or changes in behavior to previously administered skilled services)
• Skilled services provided
• Resident’s response to the skilled services provided during the current visit
• Plan for future care based on the rationale of prior results
• Detailed rationale that explains the need for the skilled service considering the resident’s overall medical condition and experiences
• Medical necessity supporting the complexity of the service to be performed
• Any other pertinent characteristics of the resident
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