We’ve all been waiting for this.

We knew it was coming!

What am I speaking of?

The May 4, 2023, notice of Skilled Nursing Facility (SNF) 5-Claim Probe and Educate Review, of course!

Since the initiation of PDPM in October of 2019, providers have been long awaiting medical review to assess the accuracy of interdisciplinary team documentation. 

What do rehab teams need to know?

To begin, the stated purpose of the Change Request (CR) is to have the MACs perform a 5-claim probe and educate medical review on every SNF in their jurisdiction. The purpose of the widespread review is to lower the SNF improper payment rate.

The CR is an attempt to increase comprehension of correct billing practices under the PDPM by all SNF providers that bill Medicare. 

As such, CMS is implementing a 5-claim probe and education medical review strategy that allows for maximum outreach to all SNFs and offers provider-specific education, as necessary, to prevent future improper payments.

The key elements of this project include:

  • All MACs that review SNF Medicare claims
  • MACs will select 5 claims from each selected provider. 
  • MACs will complete one (1) round of probe and educate for each selected provider instead of the potential three (3) rounds as instructed by the traditional TPE program.
  • Education offered will be individualized based on the claim review errors identified in the probe. 

When will this start? 

Effective date: June 5, 2023

Why is CMS going to be reviewing claims? 

The Comprehensive Error Rate Testing (CERT) program for SNFs (skilled nursing facility) projected an improper payment rate of 15.1% in 2022, up from 7.79% in 2021. 

Furthermore, SNF service errors were determined to be the top driver of the overall Medicare Fee-for-Service improper payment rate. Part of the reason for the significant increase in the improper payment rate may be the change from the Resource Utilization Group (RUG) IV to the PDPM (patient driven payment model) for claims with dates of service on or after October 1, 2019. 

What is the main reason for errors?

The primary root cause of SNF errors was found to be missing documentation.

What can therapy teams do to prepare and support their communities?

To begin, ensure all team members understand which areas of the MDS are associated with therapy HIPPS elements from PDPM and assess interdisciplinary coding systems and accuracy within your site.

Physical and occupational therapy are tied to clinical category and a functional score which is calculated as the sum of the scores on 10 Section GG items: 

  • Two bed mobility items 
  • Three transfer items 
  • One eating item 
  • One toileting item 
  • One oral hygiene item 
  • Two walking items

Speech pathology within PDPM uses a number of different patient characteristics that were predictive of increased SLP costs, including:

  • Acute Neurologic clinical classification 
  • Certain SLP-related comorbidities 
  • Presence of cognitive impairment 
  • Use of a mechanically-altered diet 
  • Presence of swallowing disorder

Next, review the CR with the entire interdisciplinary team to ensure everyone collectively understands the direction given to MACs to ensure timely submission of data.

These elements include:

  • Contractors shall review a sample of claims for each SNF in their jurisdiction that submits claims for Medicare SNF services. NOTE: Contractors shall amend their current medical review strategies to institute this instruction within their normal operating budgets.
  • Contractors shall select a sample of 5 claims for prepayment review (with occasional post-pay, if requested by the provider due to financial burden) from the universe of claims for all SNFs that submit claims for Medicare SNF services within the contractor’s jurisdiction.
  • The contractors shall implement the SNF 5-claim reviews on a rolling basis beginning with the top 20% of providers that show highest risk based on MAC data analysis.

What should teams expect after review?

  • After an individual provider’s 5-claim sample is completed, contractors shall send detailed results letters.
  • For providers with error rate 20% or less (1/5 claims in error) MACs shall provide widespread education with the option for the provider to receive 1:1 education, if requested.
  • Additionally, in the results letters for providers with error findings >20% in their sample, contractors shall offer 1:1 education.
  • “When the provider accepts 1:1 education the MACs shall provide education that includes claim specific information (i.e., clinical facts and corresponding denial reasons) and that allows the provider the opportunity to review the claim decisions, ask questions and receive meaningful feedback conducive to behavioral change and increased provider compliance.

Finally, take advantage of the follow-up education! 

Having the opportunity to engage with your contractors, speak with reviewers, and learn best practices for coding and documentation not only benefits your teams but also the patients you serve daily.

Ready, set, review. The time is now.

Want to learn more?

CMS lists the following contacts:

Pre-Implementation Contact(s): Heather Wetherson, [email protected] , Susan Shuman, [email protected]

Post-Implementation Contact(s): Contact your Contracting Officer’s Representative (COR).

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected] 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.