A strong Triple Check process requires a group effort

The Triple Check process is an internal audit that ensures billing accuracy and compliance with regulatory guidelines prior to the submission of claims to Medicare and other payors. A strong Triple Check process requires a group effort from the Interdisciplinary team in order to validate care and services, supportive documentation and billing accuracy.

SNF Triple Check updates will be necessary with the transition to the Patient Driven Payment Model (PDPM) on October 1, 2019. The Final Rule specifies that “the information reported to CMS must be accurate. Inaccuracies in the data reported to CMS, or a failure to document the basis for such data, will necessitate … administrative actions.” (pg. 39198 click here for this resource)

Triple Check is a critical component of Medicare compliance and should be included on the list of transition action items in preparation for PDPM. Under PDPM, SNF processes should include validation beyond checking therapy minutes and activities of daily living (ADL) coding. Providers will need to validate each PDPM component, including the multiple layers of classification and coding included in each Case Mix Group (CMG) to ensure services are appropriately coded and documented to reflect each relevant resident characteristic. Providers must have a robust Triple Check process in place to ensure the case mix group assignment and HIPPS codes are coded accurately and well supported in the medical record for each coded element impacting reimbursement.

Common Billing Errors To Consider in your PDPM Triple Check Process:

  • Claims submission prior to validating accurate HIPPS code and supporting documentation
  • Inappropriate coding of the primary SNF condition
  • Coding sections of the MDS without an active condition/diagnosis &/or care need
  • Erroneous omission of ICD10 codes to support conditions relevant to the NTA, nursing, and SLP categories
  • Supporting documentation to accurately describe the presence of swallow impairment
  • Proof of physician oversight such as signed and dated orders, timely physician visits, or compliant SNF certification / recertifications

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PDPM Billing Compliance Quick List

Update current forms to include validation of primary reason for SNF care (MDS I0020B), applicable surgical history, active diagnoses in MDS section I with supporting care plans, rehab group/concurrent compliance, and documentation that effectively supports each character of new 5-digit HIPPS codes applied to the Medicare claim.

Key risk areas associated with billing accuracy:

  • Physician SNF Certification
  • Clear Support for each Case Mix Group
  • Mechanically Altered Diets & Swallow Impairments
  • Therapy Intensity justification as determined by resident clinical needs
  • >25% Group/Concurrent
  • Over use of IPA
  • Inaccurate application of Interrupted Stay Policy (e.g. MDS completion)
  • Billing for services not provided or rendered

PDPM Triple Check Billing Accuracy Toolkit

This tool kit is intended to assist facilities in establishing and/or updating existing processes to promote clean claims for accurate billing and preparing Triple Check team members for an effective and compliant process in “clean claims” through pre-bill review. Click here to get all the details and download this resource in our shop.

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Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Director of Audit Services, Proactive Medical Review

Click here to learn more about Stacy and the rest of the Proactive team.