On May 4th, CMS issued Transmittal 12015 instructing MACs to perform a 5 claim probe and educate medical review on every SNF in their jurisdiction. A 15.1% SNF error rate in 2022 based on the Comprehensive Error Rate Testing (CERT) program is the catalyst for this action (see 2022 Improper Payment Data). SNFs had the highest error rates of all FFS provider types with the 15.1% error rate nearly double that of the 7.79% error rate in 2021. According to the CERT report, the primary root cause of SNF errors was insufficient documentation (73.2% of all error), the majority of which was related to missing Case-Mix Group (CMG) component documentation. The CMS directive to initiate a probe audit across all SNFs in the nation is an attempt to increase correct PDPM billing practices.
MACs have been instructed to complete the following (implementation date – June 4, 2023):
- Implement a process to select and review 5 claims for each SNF in their jurisdiction that submits claims for Medicare SNF services
- Current medical review strategies must be amended to institute this instruction within the MACs normal operating budget
- The process will be implemented on a rolling basis, beginning with the top 20% of providers that show highest risk based on data analysis
- The sample selection will be for prepayment review (with occasional post-pay, if requested by the provider due to financial burden)
- 1 round of the probe and educate will be completed (instead of the potential 3 rounds under the traditional TPE program)
- Providers must receive detailed results letters, even with no error findings
- MACs must offer 1:1 education to providers with error findings >20% in their sample
- Providers under review by other contractors will be excluded from this project
- At the conclusion of the project, MACs will prioritize TPE review for providers with 5/5 claims in error, if SNF is included in the MACs existing Medical Review Strategy
Anticipating prepayment reviews, providers should perform a triple check to facilitate claims accuracy with careful attention paid to ensuring the CMGs for each HIPPS code is clearly supported in the patient record.
Contact Proactive to schedule a sample coding and documentation audit or to learn more about Medical Review support services including ADR preparation, pre-submission ADR previews, and Medicare appeals management.
Written By: Stacy Baker, OTR/L, RAC-CT, CLNC
Director of Audit Services
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