Medicare Certification Process – Setting the Stage for Success

By April 18, 2017Newsletter Article

Authored by Suzy Harvey, RN-BC, RAC-CT from  BKD, LLP

According to a 2015 Comprehensive Error Rate Testing (CERT) Report recently released by the Centers for Medicare and Medicaid Services (CMS), “the denial rate for Skilled Nursing Facilities (SNFs) increased from 6.9% to 11% due to missing or incomplete certification/recertification.” A certification that the beneficiary requires daily skilled care that can only be provided in a SNF/swing bed setting is key to Medicare Part A coverage and claim approval. The SNF must obtain and retain the certification and recertification statements as Medicare Administrative Contractors or other Medicare contractors may request them as part of a medical review to determine if SNF services were reasonable and necessary.

CMS does not require a specific format for the certification or recertification process but does have a list of requirements that need to be met for the resident’s stay to be deemed valid.

The certification process is not the same as an order to admit to the SNF or an order for a skilled level of care. A separate statement indicating the resident will require on a daily basis SNF covered skilled care is required. The initial certification must be obtained at the time of admission, or as soon thereafter as reasonable and practicable. BKD recommends the physician certification be signed within the first two days of admission. Faxed signatures are acceptable.

The initial certification must clearly indicate that;

  • Skilled nursing or rehabilitation services are required on a daily basis,
  • The services can only be provided in the SNF or swing bed hospital on an inpatient basis, and
  • Services are for a condition that was treated or arose during the qualifying hospital stay.

The initial certification must be signed and dated by a physician or non-physician provider (NPP).

The first recertification statement is required no later than day 14 of the SNF stay. Subsequent recertification are required at intervals not exceeding 30 days from the physician’s dated signature on the previous recertification.

The recertification statements must contain the following information.

  • The reason(s) for continued post hospital SNF care,
  • The estimated length of continued SNF stay,
  • Discharge or home care plans, and
  • Continued SNF services are for a condition that was treated or arose during the qualifying hospital stay.

Each recertification statement must be signed and dated by the physician or NPP within 30 days of the previous recertification date.

CMS does not provide a set time frame, but does accept or honor delayed certifications and recertifications where there has been an isolated oversight or lapse in getting them completed. Delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the SNF considers relevant for purposes of explaining the delay.

A certification or recertification statement must be signed by the attending physician or a physician on staff at the SNF who has knowledge of the case, or by a NPP, which includes a nurse practitioner, a clinical nursing specialist or physician assistant who has no direct or indirect employment relationship with the facility but who is working in collaboration with the physician. SNFs should provide education and information from CMS on the certification/recertification process to all physicians on staff.

Medicare contractors will request and review the certification and recertification process for all medical reviews which can include; additional documentation requests (ADRs), probe reviews or recovery audit reviews. If the certification or recertification is missing or incomplete as indicated by the 2015 CERT report, the review ends and the claim is automatically denied. Don’t let this happen to your Facility.

Can other documentation be used in place of the certification/recertification process? The answer is yes but if a physician’s order or progress notes are used they must contain all information required. If any of the information required is not included in the physician order or progress note then it is not a valid certification or recertification.

See the example included with this article to help your SNF ensure timely and accurate physician certification process. Required documentation for the certification and recertification is highlighted.

Contact your BKD advisor if you have any questions.

Article reprinted with permission from BKD, LLP, All rights reserved.