Medicare Compliance & Reimbursement

Reviewing the Medicare coverage rules for skilled nursing facility (SNF) care can be one of the best moves you can make to protect your facility's bottom line.

In a nutshell: "There are basically three requirements for patients who have Part A," says Victor Kintz, MBA, CHC, LNHA, RAC-CT, CCA, managing director of operations with the Polaris Group in Tampa, Fla.

1. A qualifying inpatient hospital stay that covers three midnights. Stays that turn out to include observation days can throw a monkey wrench in this technical requirement. So as part of "due diligence," the facility should verify prior to admission that the beneficiary's hospital days are, in fact, "inpatient," says Kintz.

2. The "practical matter" requirement. This means that "for a variety of reasons including safety," the beneficiary as a "practical matter" needs to receive the services as an inpatient, Kintz says. "This is an area that will surely receive more scrutiny moving forward."

Counter this potential source of claims denials: If a patient's discharge plans call for him to return to independent or assisted living, the clinical record should address why the person couldn't have received the services on an "outpatient" basis, Kintz counsels. "This would primarily relate to therapy services."

3. Need for a medically necessary, daily skilled service. For nursing services, that's defined as seven days per week -- for therapy, it's at least five days per week, Kintz says.

Also: The physician must order and certify/recertify the need for skilled services, Kintz says. And the resident's record must include the appropriate documentation and support to justify the benefit, he adds.