As most providers are aware, the Centers for Medicare & Medicaid Services (CMS) suspended most Medicare fee-for-service medical reviews because of the COVID-19 pandemic on March 30, 2020. This included pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate (TPE) program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors, and Recovery Audit Contractors (RACs).

In August, despite the ongoing public health emergency, CMS indicated that it would be authorizing Medicare contractors to resume conducting pre-payment and post-payment audits, prioritizing post-payment reviews of COVID claims submitted before March 1, 2020.

Refer to the following tips to ensure compliance with Medicare Skilled Level of Care decisions and prepare for waiver-related claims audits:

Understand the Waiver

CMS issued a waiver for Long Term Care Facilities and Skilled Nursing Facilities (SNFs) relating to the 3-day qualifying hospital stay. It states in part:  using the authority under Section 1812(f) of the Act, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who experience dislocations, or are otherwise affected by COVID-19. In addition, for certain beneficiaries who exhausted their SNF benefits, it authorizes renewed SNF coverage without first having to start a new benefit period (this waiver will apply only for those beneficiaries who have been delayed or prevented by the emergency itself from commencing or completing the process of ending their current benefit period and renewing their SNF benefits that would have occurred under normal circumstances).

Under this waiver, all Part A beneficiaries qualify, regardless of whether they have benefit days remaining, however, the provider must demonstrate that the resident’s continued receipt of skilled care in the SNF, beyond the original 100 days of Medicare coverage, is in some way related to the public health emergency. Once providers determine that a resident qualifies for skilled services using the waiver, they should document the rationale in a progress note. This will assist the facility should they ever find themselves in an audit review.

MLN Matters Special Edition article SE20011, Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) explains that “this determination basically involves comparing the course of treatment that the beneficiary has actually received to what would have been furnished absent the emergency [i.e., if the emergency had not occurred]. This would not apply to those beneficiaries who are receiving ongoing skilled care in the SNF that is unrelated to the emergency. In making such determinations, a SNF resident’s ongoing skilled care is considered to be emergency-related unless it is altogether unaffected by the COVID-19 emergency itself (that is, the beneficiary is receiving the very same course of treatment as if the emergency had never occurred).”

Ensure Coverage Eligibility

Once we understand the waiver requirements, we then have to ask ourselves if we can confirm coverage eligibility. Even in the pandemic, a skilled level of care must still exist to skill a resident under Medicare Part A. Simply having a diagnosis of COVID is not enough. The Medicare Benefit Policy Manual outlines these requirements in Chapter 8, Section 30.

        • The patient requires skilled nursing services or skilled rehabilitation services (§30.2-30.4)
        • The patient requires these skilled services on a daily basis (nursing 7d/w, and/or therapy 5-7d/w) (§30.6)
        • As a practical matter, the daily skilled services can be provided only on an inpatient basis in a SNF (§30.7)
        • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury
        • At a minimum, the following skilled nursing services furnished during CDC/CMS 14-day isolation guidance can likely be justified due to a “reasonable probability” of COVID-19 symptom appearance or exacerbation based on CDC Morbidity and Mortality Weekly Reports”:
            • Management and Evaluation of a Patient Care Plan (§
            • Observation and Assessment of Patient’s Condition (§
            • Teaching and Training Activities (§
            • Detailed CDC guidance on steps to Evaluate and Manage Residents with Symptoms of Respiratory Infection in SNF under COVID-19 which could be included in supporting documentation can be found here.

On April 5th, CMS provided guidance for new admissions based on the §1135 waivers. For new admissions that have a positive test and are showing clinical signs and symptoms or are asymptomatic, Part A coverage is likely but would be subject to CDC/CMS Isolation Guidance for New Admissions and of course be dependent on skilled care requirements outlined in Chapter 8 of the Medicare Benefit Policy Manual. For those with results pending or those that have not been tested, skilled coverage is determined based on skilled care requirements, however, coverage beyond symptom resolution and the isolation period would be dependent on requirements in Chapter 8 of the Medicare Benefit Policy Manual. Lastly, those with a negative test result, those with results pending, or those untested that are not exhibiting signs or symptoms could potentially be covered under skilled nursing observation and assessment until the end of the 14 day period identified in the CDC/CMS Isolation Guidance for New Admissions, or if symptoms appear.

CMS provided the same guidance for current nursing facility residents. Should a current resident develop a need for skilled care and the last benefit period is either more than 60 days prior, or less than 60 days prior, they are likely covered under Part A, as long as the requirements in Chapter 8 of the Medicare Benefit Policy Manual are met and the new skilled service(s) would likely prevent the need for emergency room or hospital inpatient care, the §1135 waiver can be applied. This includes long term residents that become COVID positive with symptoms, without symptoms, or are symptomatic and are presumed positive. These residents may require skilled nursing observation and assessment for 14 days. For those residents who exhausted their 100 Day SNF Benefit, continue to receive ongoing skilled care, and/or have a change in status requiring different skilled services, skilling in the facility addresses the skilled care need without tying up hospital resources or exposing patients unnecessarily to COVID-19. These residents are potentially covered, as long as the requirements in Chapter 8 of the Medicare Benefit Policy Manual are met and the new skilled service(s) would likely prevent the need for emergency room or hospital inpatient care. Finally, those residents who exheausted their 100 Day SNF benefit, continue to receive ongoing skilled care, and/or intermittent Part B PT/OT/SLP services but are otherwise stable, Part A services would likely not be covered as a stable condition would not generally need emergent or hospital inpatient services.

As a best practice for any organization, consider a policy outlining when to use the waiver. Once the facility determines the waiver applies, documenting the care that meets the waiver requirements will be needed. Providers can find more information on blanket waivers, requirements, and COVID-19 FAQ’s here.

Learn more about making the decision on COVID+ and other skilled scenarios in our webinar available in the Proactive shop!


Blog by Jessica Cairns, RN, RAC-CT, CMAC, Proactive Medical Review

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