According to the most recent Comprehensive Error Rate Testing (CERT) report released by the Centers for Medicare & Medicaid Services (CMS), $2.7 billion in improper payments were projected for Skilled Nursing Facility (SNF) services for 2021. Inadequate documentation for Physician’s Certifications/Recertifications accounted for over 35% of errors contributing to improper payments. Likewise, SNF certification/recertification accuracy ranks among the top errors Proactive finds in Medicare compliance reviews. With this in mind, this week’s blog examines SNF certification/recertification requirements, and top mistakes to avoid…
While no specific form is mandated to be used for Physician Certification/Recertification, the documentation must include all required components and meet timeliness criteria.
Certification Required Criteria:
- The individual needs skilled nursing or rehabilitation services
- Services are required on a daily basis (nursing = 7 days a week; therapy = 5 days a week)
- Services can only practically be provided in the SNF or swing bed hospital on an inpatient basis
- Services are for an ongoing condition for which the individual received inpatient care in a hospital, or arose during the SNF stay
- The initial certification must be signed and dated by a physician or nonphysician provider (NPP)
Recertification Required Criteria:
- Reason(s) for continued post-hospital SNF care
- Estimated time the individual will need to remain in the SNF
- Discharge or home care plans
- Whether continued SNF services are for a condition that was treated or arose during the SNF stay
- A dated signature of the recertifying physician or NPP
Timing of Certifications and Recertifications:
- The certification must be obtained at the time of admission or as soon thereafter is reasonable and practicable
- The first recertification is required no later than the 14th day of post-hospital SNF care
- Subsequent re-certifications are required at least every 30 days after the first recertification
- Each recertification statement must be signed and dated by the physician or NPP within 30 days of the previous recertification date
- SNFs are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an isolated oversight or lapse. In addition to complying with the content requirements, 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
Who May Sign the Certification or Recertification:
- A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, a physician assistant) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician.
Medical Review of Certification and Recertification:
- Medicare contractors will request and review the certification and recertification process for all medical reviews, which can include additional documentation requests, TPE, probe reviews or recovery audit reviews. If the certification or recertification is missing or incomplete, the review can end and the claim will likely be automatically denied.
- CMS instructs MACs to consider documentation in the beneficiary’s medical record beyond a discrete certification or recertification form to determine if the required elements for certification are present. While the certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, they must contain all information required. If any of the required information isn’t included, then certification or recertification is not valid.
Avoiding Common SNF Certification / Recertification Process Errors:
- Establish a policy for obtaining timely initial certifications.
- The certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable. Often times, reviewers will determine 72 hours as meeting the “reasonable” timeframe. However, providers are to determine a timeframe that is reasonable and should consistently follow their established policy and procedure for complying with that timeframe.
- Ensure the first recertification due date is properly counted.
- When counting the due date for the first certification, providers must include day one of the PPS stay. Often, we find day one of the stay is skipped, and subsequently the recertification is signed one day late.
- Keep in mind, the first recertification can be obtained at the time of the initial certification, but no later than PPS day 14.
- Include all technical components of the recertification requirements.
- Most providers opt to use a certification / recertification form in order to ensure each required component is consistently included in documentation. Unfortunately, technical criteria are sometimes erroneously omitted from internally developed form templates (e.g.; Estimated time the individual will need to remain in the SNF and/or Discharge or home care plans).
- Include the individualized estimated times that each resident requiring SNF care is anticipated to need, and the person-centered reason(s) for post-hospital SNF care.
- Beneficiaries receiving SNF care on your campus will generally require skilled services for varying conditions and services, as well as for varying lengths of stay. Avoid using global timeframe estimates (e.g.; 30 days) or generic reasons for skilled services (e.g.; strengthening, therapy services, etc.).
- The interdisciplinary team should collaborate to determine the estimated time the patient will require SNF care based on prior level of function, clinical condition(s), comorbidities, and discharge goals.
- As a best practice, the reason(s) statement for post-hospital SNF care should include the nursing and/or therapy daily skilled need, as well as commodities and services the patient is anticipated to receive during the SNF stay.
- Ensure the physician / physician extender dates the signature.
- Providers should not date the physician / physician extender signature, nor should dates be pre-populated onto the form. Reviewers may question visual variation of the physician signature versus the signed date.
- Understand that stamped signatures are prohibited unless the signee has a physical disability and can prove to a CMS contractor inability to sign due to that disability.
- If electronic signatures are used, follow the defined facility policy and ensure that e-signatures are timestamped
- Include SNF certifications and recertification review within your routine triple check meeting.
- The Medicare conditions of payment require a physician certification and (when specified) recertification for SNF services. Providers should determine accuracy before releasing claims.
- Utilize triple check as your internal monitoring to determine education needs.
Contact Proactive to schedule a remote Medicare compliance audit or to learn more about Medical Review support services including ADR preparation support and Appeals management.
- Code of Federal Regulations – Conditions for Medicare Payment: eCFR: 42 CFR Part 424
- Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Section 40: Certification and Recertification by Physicians for Extended-Care Services
- Medicare Benefit Policy Manual, Chapter 8, Section 40: Physician Certification and Recertification of Extended-Care Services
- Medicare Program Integrity Manual, Chapter 5, Section 6.3: Medical Review of Certification and Recertification of Resident’s in SNFs
- Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Chapter 6, Section 6.5, SNF PPS Eligibility Criteria (Physician Certification)
- The MLN Network fact sheet Complying With Medicare Signature Requirements offers answers and resources related to Medicare signature requirements, including dating requirements and how to use signature logs or attestation statements to support illegible signatures.
- U.S. Department of Health & Human Services: 2021 Medicare Fee-for-Service Supplemental Improper Payment Data
Stacy Baker, OTR/L, CHC, RAC-CT
Director of Audit Services