Q: What are some of the common findings from the SNF 5-Claim Probe and Educate Reviews?
A: In an attempt to lower the skilled nursing facility improper payment rate, CMS implemented the SNF 5-Claim Probe and Educate Review, wherein the Medicare Administrative Contractors (MACs) conduct reviews of five claims for every SNF in their jurisdiction.
If improper payment is identified, the MAC will adjust the individual claim payment in addition to providing education on Medicare requirements for inpatient SNF care. Here are some common review findings to consider and try to avoid:
• Documentation does not support the level of service shown on the claim.
• No MDS was found in the repository.
• Documentation is insufficient for the services billed.
• Documentation doesn’t support required (re)certifications, nor that SNF services were medically reasonable and necessary.
As expected, Section GG of the MDS is called out specifically. Documentation is either not provided or is insufficient to support usual performance codes. For example, variations in the assessments provided by multiple disciplines do not allow for accurate validation of the MDS, leading to the suggestion that facilities should identify the document source(s) used to code the MDS.
Active diagnoses in Section I remain an issue, too. A diagnosis should be reported only in the MDS if active, defined as physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, treatments, nursing monitoring, or risk of death during the seven-day look-back period.
Note: Be wary of conditions auto populated by your software.
From the April/May 2024 Issue of McKnight's Long-Term Care News
