MDS Alert

Get the required info on time and know what to do if you don't.

Failure to obtain proper Part A physician certs or recerts can leave your SNF holding the bag for claims denials and fending off major compliance woes.

In performing RAC readiness audits, consultant Jane Belt, MS, GCNS-BC, RAC-MT, has uncovered "basic problems" with physicians not providing needed information in the certification and/or recertification for skilled care. Other experts report similar problems, including SNFs not consistently obtaining certs/recerts.

Review the nuts and bolts: The resident's attending physician or a physician on staff at the SNF who is familiar with the resident's case can sign the certification or recertification statement. So can a nurse practitioner or clinical nurse specialist who doesn't have a direct or indirect employment relationship with the SNF but is working in collaboration with the physician (www.cms.hhs.gov/manuals/downloads/ge101c04.pdf).

"A physician assistant cannot certify/recertify Part A SNF care," says Pauline Franko, PT, MSCP, owner of Encompass Consulting and Education in Tamarac, Fla.

The SNF must obtain the initial certification at admission or as soon after as is "reasonable and practical," according to CMS. The first recertification must occur no later than the 14th day of admission (or earlier, if  he SNF chooses), and at subsequent intervals not exceeding 30 days.

"The initial physician certification statement just has to have language [stating] that the resident requires an inpatient daily skilled service for any condition treated in the hospital," says Ron Orth, RN, NHA, CPC, RACMT, president of Clinical Reimbursement Solutions LLC in Milwaukee.

Recerts, on the other hand, must include the reason for the skilled services -- that is "what [nursing or rehab services] the person requires -- and the estimated length of time the person will require skilled services," Orth instructs. Also, include any plans for home care, if applicable.

Don't miss this: "If the reason for skilled care is for a new condition that developed while in the SNF [Part A stay], the recertification has to identify that condition," Orth advises.

Good idea: Rather than just putting diagnoses in certs/recerts, Orth advises using language such as "PT/OT per plan for after-care for hip fracture" or "IV therapy for diagnosis of pneumonia, or observation and assessment of unstable cardiac or respiratory status," etc.

"Medicare does not specifically require a form for physician certification/ recertification," Orth notes. "The information required for the cert/recert can be anywhere in the clinical record signed by a physician -- for example, the progress notes."

Yet, Orth recommends using aform "because it helps to maintain the schedule for obtaining the cert/recert." And the form includes the "pertinent information," which sidesteps a scenario where medical reviewers claim the SNF clinical record lacks sufficient information to comply with the cert/recert requirement, he says.

Forms can be a problem, however, if the physician or nurse practitioner simply signs them without filling in the appropriate information. "You can use checkboxes for some of the information, but the information needs to be complete before obtaining the physician or nurse practitioner signature," Orth says.

You also have to find a way to stay on top of certs/recerts. "Many facilities include the verification of certs/recerts in their end of month billing review," says Orth. He recommends taking that a "step further and reviewing them weekly during Medicare meetings to ensure" that staff obtains them on time.

Explain a delay: CMS allows SNFs "to obtain a cert/recert after the fact in the case of an isolated oversight or lapse," says Orth. The SNF needs to provide an explanation for delayed certs/recerts and any medical or other evidence to explain the delay, according to CMS. "You aren't supposed to bill Medicare without the cert or recert," Orth cautions.

Knowingly doing so, adds Franko, constitutes a false claim.

What if the MAC or FI denies a claim due to what it maintains is lack of a bona fide physician certification or recertification? "Review the clinical record and use any information that you feel would meet the requirements for the cert/recert, and appeal," advises Orth.

"If the SNF didn't obtain a cert/recert or one that includes the appropriate information, it can obtain a delayed certification and present that upon appeal," indicating it's a delayed certification, says Franko.