Q: Insufficient Documentation is the top SNF error leading to improper payment. What does this mean?

A: Insufficient Documentation is a broad error category that can include many different issues. The most prevalent is missing documentation to support Case Mix Group (CMG) components. 

Briefly, this means that something impacting reimbursement was reported on the MDS, but documentation was not present (or not provided) to validate the condition, care or service. Remember that MDS coding is often complicated and must adhere to the RAI coding requirements. 

Other examples of insufficient documentation include inadequate or missing orders, missing signature logs, missing therapy plans of care, and inadequate or missing physician certification/recertifications — a low-hanging fruit that can lead to quick denials. 

This emphasizes the importance of ardent claim review or “triple-check” processes for providers. Careful attention should be paid to ensuring the CMGs for each HIPPS code are clearly supported in the patient record. Additionally, ensure physician certification/recertification requirements are met. 

In an attempt to lower the SNF improper payment rate, CMS recently implemented the SNF 5-Claim Probe and Educate Review. If the Medicare Administrative Contractor identifies an improper payment, it will adjust payment, as appropriate, in addition to providing education. 

If you feel your review process is robust and your claims are clean, consider the effectiveness of your ADR response.  Organize documentation to facilitate ease of review by the contractor and allow sufficient time for staff with clinical and MDS coding expertise to review the claim and related documentation for accuracy before submission. 

Eleisha Wilkes, RN, is a clinical consultant with Proactive Medical Review. Send your payment-related questions to Eleisha Wilkes at [email protected].