Medicare Certification Process – Setting the Stage for Success
Author: Suzy Harvey
According to a 2015 Comprehensive Error Rate Testing report recently released by the Centers for Medicare & Medicaid Services (CMS), the denial rate for skilled nursing facilities (SNFs) increased from 6.9 percent to 11 percent due to missing or incomplete certification/recertification. A certification that the beneficiary requires daily skilled care that can only be provided in a SNF/swing bed setting is key to Medicare Part A coverage and claim approval. The SNF must obtain and retain certification and recertification statements, as Medicare Administrative Contractors or other Medicare contractors may request them in a medical review to determine if SNF services were reasonable and necessary.
CMS doesn’t require a specific certification or recertification process format but does have a list of requirements to be met for the resident’s stay to be deemed valid.
The certification process isn’t the same as an order to admit to the SNF or an order for a skilled level of care. A separate statement indicating the resident will require SNF-covered skilled care on a daily basis is required. The initial certification must be obtained at the time of admission, or as soon thereafter as reasonable and practicable. BKD recommends the physician certification be signed within the first two days of admission. Faxed signatures are acceptable.
The initial certification must clearly indicate:
- Skilled nursing or rehabilitation services are required on a daily basis
- Services only can be provided in the SNF or swing bed hospital on an inpatient basis
- Services are for a condition that was treated or arose during the qualifying hospital stay
The initial certification must be signed and dated by a physician or nonphysician provider (NPP).
The first recertification statement is required no later than day 14 of the SNF stay. Subsequent recertification is required at intervals not exceeding 30 days from the physician’s dated signature on the previous recertification.
The recertification statements must contain:
- Reason(s) for continued post-hospital SNF care
- Estimated length of continued SNF stay
- Discharge or home care plans
- Whether continued SNF services are for a condition that was treated or arose during the qualifying hospital stay
Each recertification statement must be signed and dated by the physician or NPP within 30 days of the previous recertification date.
CMS doesn’t provide a set time frame, but does accept or honor delayed certifications and recertifications where there has been an isolated oversight or lapse in getting them completed. Delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence the SNF considers relevant for purposes of explaining the delay.
A certification or recertification statement must be signed by the attending physician, a physician on staff at the SNF who has knowledge of the case or an NPP, which includes a nurse practitioner, clinical nursing specialist or physician assistant who has no direct or indirect employment relationship with the facility but is working in collaboration with the physician. SNFs should provide education and information from CMS on the certification/recertification process to all physicians on staff.
Medicare contractors will request and review the certification and recertification process for all medical reviews, which can include additional documentation requests, probe reviews or recovery audit reviews. If the certification or recertification is missing or incomplete as indicated by the 2015 CERT report, the review ends and the claim is automatically denied. Don’t let this happen to your facility.
Other documentation can be used in place of the certification/recertification process, but if a physician’s order or progress notes are used, they must contain all information required. If any of the required information isn’t included in the physician’s order or progress notes, then it’s not a valid certification or recertification.
See our sample Physician Certification and Recertification Form to help your SNF ensure a timely and accurate physician certification process. The required documentation for the certification and recertification is highlighted in the example.
Contact your BKD advisor if you have any questions.