Skilled Nursing Facility RUG Utilization

Wisconsin Physicians Service (WPS) Medical Review (MR) is providing this article to update providers on the status of service specific prepay edits. MR service specific complex review edits are commonly know as prepay edits. These prepay edits suspend claims from multiple providers when a claim is submitted for payment which includes specific coding criteria for that service.

This article details the initiation of a service specific edit. WPS MR prepay edits are continually reviewed based on reviewed claim data. Edits are modified or terminated as data analysis supports decreased vulnerability to the Medicare Trust Fund and/or workload analysis.

The following MR service specific prepay edits in the WPS MAC J5 region are active.

Applies to the States of: Iowa, Kansas, Missouri, and Nebraska

Reason Code: 50SNF

Date Initiated: February 8, 2010

This prepay edit is the result of: Post pay Probe reviews

Probe reviews were conducted on skilled nursing facilities (SNF) billing ultra high, very high, and high rehabilitation resource utilization groups (RUGs) with various assessment modifiers. Probe results from Fiscal Year 2009 (FY09) and Fiscal Year 2010 (FY10) have been collected and analyzed for these SNF services. The average error rate for dollars billed in error was 41.6%. The average error rate for claims billed in error was 70.1%. A prepay edit has been initiated for all providers billing the specific criteria identified from our Probe data analysis.

Complex medical review will be performed on claims which suspend for the above reason code which match the billing criteria. The most common reasons for denial for this service are listed below:

Page Last Updated: Tuesday, 02-Aug-2011 15:06:26 CDT