Comprehensive Error Rate Testing (CERT) Denial of Skilled Nursing Facility Claims Due to Lack of Documentation
Recent CERT data indicates there have been several Part A Skilled Nursing Facility (SNF) claims paid in error. These claims represent 39% of the total dollars in error for the current CERT reporting period for claims processed from April 01, 2006 to March 31, 2007. These are dollars that we have recouped. The reason for these errors continues to be lack of documentation to support the RUGIII level billed.
The most common errors made by providers are 1) failing to include all look-back documentation and 2) lack of therapy minutes.
The applicable look-back period may be in a previous or subsequent month of the billing period. Examples of these two situations are as follows:
Example 1 - A patient is admitted to the SNF on February 18, 2006. The Assessment Reference Date (ARD) for the 5-day assessment is February 22, 2006. The dates of service being reviewed are March 01 to March 31, 2006. All documentation for the month of February should be included to support the look-back periods for the 5-day and 14-day assessments since the RUGIII category billed is determined by the skilled services provided during the 7 to 14 days prior to the ARD.
Example 2 - A patient is admitted to the SNF on March 30, 2006. The ARD is set on the 5th day, which is April 03, 2006. The dates billed are the 30th and 31st of March, but the look-back period is March 30 to April 03, 2006. In this example, the documentation should include the first three days of April, since the look-back dates start with the ARD and the skilled services provided during the last two days of March and the first 3 days of April would determine the RUGIII category billed.
The lack of documentation of therapy minutes also may result in the claim being down-coded, thus reducing payment. In some cases, therapy minutes are recorded on a separate grid, which should be included in the patient's chart. In some facilities, the therapy documentation is kept in the therapy department. It is recommended that the therapy department be consulted to make sure that all applicable documentation for all look-back periods is included.
Finally, it may be to the benefit of the facility to have all outgoing documentation copies checked by clinical personnel in order to avoid documentation errors. Please refer to the "Medical Review" section our Website for a complete list of documentation needed for medical review.
It is important to remember that CERT documentation requests must be responded to in a timely fashion. Late documentation is accepted by the CERT contractor, however, money may be recouped prior to review of the late documentation.
Page Last Updated: Tuesday, 15-Jul-2008 10:34:58 CDT
