Source: https://www.noridiansmrc.com/current-projects/01-026/
Timestamp: 2020-04-07 17:40:55
Document Index: 80432932

Matched Legal Cases: ['§1812', '§1813', '§1814', '§1815', '§1819', '§1861', '§1862', '§1879', '§1888', '§409', '§409', '§409', '§409', '§409', '§409', '§409', '§411', '§413', '§413', '§413', '§413', '§413', '§413', '§413', '§413', '§413', '§413', '§424', '§424', '§483', '§483', '§483', '§483', '§483', '§483', '§483', '§483', '§483', '§483', '§483', '§ 130', '§ 130', '§ 6', '§ 6']

01-026 Skilled Nursing Facility (SNF) Notification of Medical Review - Noridian - SMRC
01-026 Skilled Nursing Facility (SNF) Notification of Medical Review /
01-026 Skilled Nursing Facility (SNF) Notification of Medical Review
Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A Skilled Nursing Facility (SNF) services billed on dates of service from January 1, 2018 through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
The SNF benefit has been a topic that was reviewed by the Office of the Inspector General (OIG). In 2014 and 2016, SNF medical review projects were done by the Supplemental Medical Review Contractor (SMRC). The results of the SNF medical review projects supported additional evaluation, review, and education on the SNF benefit.
Medicare covers SNF care under the Part A benefit under certain conditions for up to 100 days. The admission must meet medical necessity requirements to qualify for payment. The SNF patient requires skilled nursing or skilled rehab services, are ordered by a physician, and services rendered are for a condition which the patient received inpatient hospital services, or for a condition that arose while receiving care in a SNF for a condition they received inpatient hospital services; The patient required the skilled services on a daily basis; and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. The services are reasonable and necessary and must be reasonable and necessary in terms of duration and quantity.
CMS tasked the SMRC, to perform data analysis and conduct medical review. The SMRC will complete medical record review on claims in accordance with applicable statutory, regulatory and sub-regulatory guidance.
0022: SNF PPS
18X: Swingbed
21X: SNF Inpatient
RUA10: Ultra-high Rehab with 4-8 ADLS – 5-day Assessment
RUA20: Ultra-high Rehab with 4-8 ADLS – 14-day Assessment
RUB10: Ultra-high Rehab with 9-15 ADLS – 5-day Assessment
RUB20: Ultra-high Rehab with 9-15 ADLS – 14-day Assessment
RUC10: Ultra-high Rehab with 16-18 ADLS – 5-day Assessment
RUC20: Ultra-high Rehab with 16-18 ADLS – 14-day Assessment
Minimum Data Sheet (MDS) Assessments (5-day, 14-day, if applicable)
Documentation to support the period of time when the beneficiary’s condition is captured by the MDS assessment (look back period). The look back period may fall outside of the dates of service under review. The documentation requested may include documentation 30-45 days prior to the dates of service (DOS) under review.
Signed and dated physician certification (and recertification, if applicable) for skilled level of care
If not signed and dated timely, letter of delay that is signed and dated by physician must be submitted
Records of patient’s condition before, during and after this billing period to support medical necessity and reason the service was provided:
Hospital discharge summary and transfer form
Records supporting skilled level of care
History and physical exam pertinent to patient’s care
Skilled services provided and patient’s response
Plan for future care based on rationale of prior results
SNF progress notes and discharge summary
Nursing notes including medication and treatment records detailing:
Oxygen therapy records
ADL charting/logs
Therapy progress notes (physical, occupational, speech/language, if applicable)
Therapy minute logs
Valid electronic and handwritten physician and/or clinician signatures
Diagnostic procedure notes, if applicable
Laboratory reports, if applicable
Advance Beneficiary Notice (ABN) of Noncoverage, if applicable
Social Security Act (SSA), Title XVIII, §§1812 (a)(2)(A). Scope of Benefits
SSA, Title XVIII, §§1813(3). Deductibles and Coinsurance
SSA, Title XVIII, §1814(2)(B). Conditions of Payment and Limitationon Payment for Services
SSA, Title XVIII, §§1815. Payment to Provider of Services
SSA, Title XVIII, §§1819(a) – (d) and (f). Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities
SSA, Title XVIII, §§1861(aa)(5). Non-Physician Providers
SSA, Title XVIII, §§1862. Exclusions from Coverage and Medicare as Secondary Payer
SSA, Title XVIII, §§1879(a)(1).Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
SSA, Title XVIII, §§1888 (e). Prospective Payment
42 Code of Federal Regulations (C.F.R.) §409.30. Basic Requirements
42 C.F.R. §409.31. Level of Care Requirements
42 C.F.R. §409.32. Criteria for Skilled Services and the Need for Skilled Services
42 C.F.R. §409.33. Examples of Skilled Nursing and Rehabilitation Services
42 C.F.R. §409.34. Criteria for “Daily Basis”
42 C.F.R. §409.35. Criteria for “Practical Matter”
42 C.F.R. §409.36. Effect of Discharge from Posthospital SNF Care
42 C.F.R. §411.15(k)(1) . Particular services excluded from coverage
42 C.F.R. §413.330. Basis and Scope
42 C.F.R. §413.333. Definitions
42 C.F.R. §413.335. Basis of Payment
42 C.F.R. §413.337. Methodology for Calculating the Prospective Payment Rates
42 C.F.R. §413.338. Skilled Nursing Facility Value-based Purchasing
42 C.F.R. §413.340. Transition Period
42 C.F.R. §413.343. Resident Assessment Data
42 C.F.R. §413.345. Publication of Federal Prospective Payment Rates
42 C.F.R. §413.348. Limitation on Review
42 C.F.R. §413.360. Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
42 C.F.R. §424.20. Requirements for Posthospital SNF Care
42 C.F.R. §424.5(a)(6) . Sufficient Information
42 C.F.R. §483.1. Basis and scope
42 C.F.R. §483.5. Definitions
42 C.F.R. §483.20. Resident Assessment
42 C.F.R. §483.21. Comprehensive Person-Centered Care Planning
42 C.F.R. §483.24. Quality of Life
42 C.F.R. §483.25. Quality of Care
42 C.F.R. §483.30. Physician Services
42 C.F.R. §483.35. Nursing Services
42 C.F.R. §483.40. Behavioral Health Services
42 C.F.R. §483.65. Specialized Rehabilitative Services
42 C.F.R. §483.315. Specification of Resident Assessment Instrument
CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Chapter 1, Section 20. Administration of the Medicare Program
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 10. Requirements General
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 20. Prior Hospitalization and Transfer Requirements
CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. Skilled Nursing Facility Level of Care General
CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40. Physician Certification and Recertification of Extended Care Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 50. Covered Extended Care Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 60. Covered Extended Care Days
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 70. Medical and Other Health Services Furnished to SNF Patients
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 10. General Exclusion from Coverage
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. Custodial Care
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 170. Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 10. Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20. Services Included in Part A PPS Payment Not Billable Separately by the SNF
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30. Billing SNF PPS Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 130. A/B MAC (A) and (HHH) Specific Instructions for Application of Limitation on Liability
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2. A Three-Day Prior Hospitalization
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2.B. Transfer Requirements
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3. Verifying Potential Errors and Taking Corrective Actions
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.1. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.3. Medical Review of Certification and Recertification of Residents in SNFs
CMS, Minimum Data Set Manual, CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.15, Effective 10/01/2017 to 09/30/2018
Program for Evaluating Payment Patterns Electronic Report (PEPPER). National-level Data Reports. National Target Area Analysis. https://pepper.cbrpepper.org/Data . April 10, 2019
CMS, Medicare Learning Network (MLN) ICN 006846 (SNF Billing Reference). Effective December 2018
CMS, MLN ICN 909067 (Medicare-Required SNF PPS Assessment). Effective October 2017