Skilled Nursing Facility Town Hall Questions and Answers

Are daily notes required for skilled rehabilitation?

Answer: Daily notes for rehabilitation are not required, however, they do support that therapy performed was skilled and supports the frequency and time were met. The notes also help to support if there was a refusal of therapy from the resident, why they missed a treatment. Residents are not able to refuse due to not being in the mood but can refuse if there is a valid medical reason for missing a treatment and must be documented within the daily notes.
The example against coding the old cerebral vascular accident mentioned a UTI. Would a UTI ever be supported as the primary diagnosis and support a skilled stay?

Answer: The lookback period for a UTI active diagnosis is 30 days. If the primary reason for the beneficiary being seen in the hospital was treatment of the UTI and now, they are coming to the SNF to build back strength, the UTI would be appropriate as the primary reason. We would look to the hospital notes/discharge summary for the primary reason for that Medicare Part A stay. This is covered in the Resident Assessment Instrument under Section I. “Indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.”
To further ask about the UTI diagnosis, if the infection is resolved but the hospital stay and inactivity exacerbated the person’s muscle wasting and atrophy, if well documented by the SNF team, could the muscle wasting support the skilled stay?

Answer: The lookback for the UTI is 30 days. In the scenario where the muscle wasting and atrophy that occurred, were secondary to that diagnosis, and therefore, if within 30 days, the primary diagnosis would be the UTI.
For the collaboration of GG scoring at admission and discharge, is an attestation of the collaboration helpful or are you looking for each department to document function summaries? (Source documents would be the CNA task performance and rehabilitation documents)

Answer: We welcome all supporting documentation for beneficiaries' functional status. We consider therapy evaluations and treatment notes, nursing assessments and notes, as well as CNA documentation of support provided when performing activities of daily living. If you have a document that multiple disciplines collaborate on to complete/attest to the three-day GG function score, we will consider this as well.
What happens if the provider receives greater than a 20% CER? CMS had said just education, but I believe the presenter said that it would go to round 2.

Answer: On the P&E audit, if the provider has a greater than 20% CER, they are offered/asked to participate in a 1:1 post-probe education session. The TPE is not a second round to the P&E. It would be round one of a TPE audit. If chosen, a notification letter would be sent to your facility. Round one of the TPE audit would not occur until a minimum of 45 days from the completion date of the P&E education session.
Do we need to provide documentation after the end of the claim dates to support skill? For example, claim dates end on 1/31 but that was only the third day. Do we need to provide service logs and daily notes for February to show that skill continued?

Answer: For this situation, submit any documentation that supports the need for continued skilled care.
Will ADR letters be sent to the facility in addition to the NGSConnex portal? Or only on the NGSConnex portal?

Answer: The ADR letter itself isn't found in NGSConnex. The status of the claim awaiting documentation can be located in NGSConnex. The ADR letter is generated from the FISS and then mailed to the provider (post-pay claims only). For pre-pay claims, ADR letters are not mailed. Once a claim has been pulled for audit in FISS, the status of the claim will change in DDE to SB600 and then to SB6001. ADR letters are then generated by FISS and can be found on pages seven and eight but can only be accessed when the claim is in location SB6001.

HMO residents, who disenroll to Medicare Part A, is documentation, from entry, required, or is it only required from the Medicare Part A start date?

Answer: Documentation is required from the seven-day lookback period through the dates of service billed for the P&E claim. Medicare Part A rules go into effect at the time of the HMO termination for the MDS, certification and other requirements. If documentation from the time of the HMO (hospital notes, diagnosis list, therapy evaluations) would support the MDS coding and skill, it would be pertinent to send that documentation as well.
Would you please explain your auditors’ qualifications to make individualized clinical decisions?

Answer: All auditors/reviewers are RNs. They undergo comprehensive and ongoing training, also consult with clinical medical directors and subject matter experts.
Do you recalculate the CER if we win on appeal?

Answer: No. The CER is not recalculated based on any redeterminations during appeal.
Can you please go over pre-pay and post-pay and explain how these audits will affect our payments during the process?

Answer: Pre-pay and post-pay claims, which are found to have errors, both have the opportunity for redetermination/appeal. Pre-Pay claims will be paid once the claim is found to be payable during redetermination. Post-pay claims, which were already paid, but found to have an error, will receive a remittance notification. Once you have filed the redetermination/appeal, that remittance will go on hold, and if found payable, you will no longer be asked to send in payment. If found to still have an error(s), the remittance would be needed.
Can we do a reconsideration (redetermination) if more documentation is needed?

Answer: Yes, especially when missing documentation was the reason for error on the initial determination. During the first round of appeal (redetermination), send in any missing documentation. It is important to make sure you look at the full decision rationale, and if there is more than one error, address all errors found during your redetermination appeal.
With my five-claim audit, I did not get the full rationale until after sending the redetermination. I did not know where to find the full rationale. I only went off the Results Letter.

Answer: The claim rationale can be found in FISS on page four or in NGSConnex under “ADR Details”, within the “ADR Summary.”
On page four, I only had codes. I just got access to FISS. How would I have known to look in FISS? I wasn’t aware to look there until my education. I guess moving forward it’s best for me to ask prior to doing a redetermination.

Answer: Here is a resource on our website, which will show you how to view rationales within NGSConnex. Also included on this page is a link to the FISS DDE User Guide, which shows you where to access rationales on page four.

Your facility’s P&E results letter contains the audit findings and denial reason codes listed. Below the audit findings, it informs the facility that they “may also refer to page four using your DDE system and the attached claim detail spreadsheet to determine your claim specific denial reasons.”
Can IV medication, which is received in the clinic, during a SNF stay, be captured in Section O, "IV Medication while a resident"?

Answer: No, only IV medications administered, while at the actual SNF can be billed for and must adhere to the following requirements. Code any drug or biological given by IV push, epidural pump or drip, through a central or peripheral port in this item. Do not code flushes to keep an IV access port patent or IV fluids, without medication, here. Epidural, intrathecal and baclofen pumps may be coded here, as they are similar to IV medications in that they must be monitored frequently, and they involve continuous administration of a substance. Subcutaneous pumps are not coded in this item. Do not include IV medications of any kind that were administered during dialysis or chemotherapy. Lactated Ringers given IV is not considered a medication and should not be coded here. Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff. Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators. Surgical procedures include routine pre and post operative procedures.
So only intravenous immunoglobulin can be captured on Section O and not other IV medications?

Answer: IV medications given during the SNF admission can be coded if they are administered by facility staff and are medically reasonable and necessary for the treatment of the beneficiary's condition. The IV administration can be coded as directed in the RAI manual, Section O, taking care to avoid coding IV medications given as chemotherapy or part of dialysis treatment.
We were pre-selected for TPE with 30 claims. Is this considered a pre-pay audit?

Answer: All claims being reviewed for the five claim P&E and the subsequent 30 claim TPE, that is related to the five claim P&E findings, are pre-pay at this time.
Will this impact the facility's operations due to the financial status of these claims being held until the review is complete?

Answer: Ideally, facilities will respond to the ADRs as they are able and reviewers will have 30 days to complete the claim review and process for payment, as appropriate. National Government Services will continue to review in a timely fashion. This would be best supported by the facility sending in all required documentation to support MDS coding and nursing/therapy skill, as well as certifications and other documentation as listed on the ADR.
We never got notification that we had ADRs to complete. We found them on NGSConnex because of a denial we received, but they were already past due. How do we prevent this in the future?

Answer: It is the responsibility of the provider to ensure their contact information is correct and up to date in the Medicare PECOS, and to monitor their mail, FISS and/or NGSConnex for ADR requests.
For therapy, you mentioned that "If functions taught by therapists are not retained because of cognitive deficits, these programs would not be reasonable and necessary." Will this result in an error even if it doesn't change the HIPPS code?

Answer: This would not necessarily result in an error with the HIPPS code (resulting in recoding); however, it could affect payment if it is determined that the care rendered was not reasonable/necessary or the skill of a therapist was not required to provide the care. Beneficiaries with cognitive impairment can participate in therapy, as long as the basis of the therapy plan is not focused on patient education.
How long does it take and how do you get notified of the five claim P&E review?

Answer: It is the responsibility of the provider to ensure their contact information is correct and up to date in PECOS, and to monitor their mail, FISS and/or NGSConnex for ADR requests.