SNF Physician Certifications for Medical Review

by | Jan 27, 2021 | Tool Box Essentials

Explore More Posts from MDS Consultants

One of the requirements of payment is a valid Physicians Certification for Medicare part A services. If SNF certifications and re-certifications are not completed and signed following CMS regulations, then the facility is at risk of losing payment for an entire claim period.

According to the Medicare Administrative Contractor, Noridian:

“Analysis of claim denials from CERT, RA and MAC contractors has identified a trending related to the failure to comply with the certification or recertification requirements.”

Providers are reminded to comply, maintain, and submit this documentation upon request to auditors to support this requirement for condition of payment. To meet requirements, the certification statement must clearly indicate that skilled services are required because of the resident’s need for skilled care on a continuing basis for which he/she was receiving inpatient hospital services.

Certification is Signed

  • By an attending physician or a physician on the skilled nursing facility staff who has knowledge of the case.
  • A nurse practitioner, clinical nurse specialist, or physician assistant does not have a direct or indirect employment relationship with the facility but is working in collaboration with the physician.
  • The signature and the date need to be completely filled out by the signing clinician. Nursing home staff cannot date the signature.

Timing of Certification / Re-certifications

  • Certification timing is counted according to Medicare days, not calendar days. Day 1 (the day of admission) is counted toward the due date of the first recertification
  • The Initial Certification is due at the time of admission or as soon thereafter as is reasonable and practicable.
  • The first recertification must be made no later than the 14th day of inpatient extended care services.
  • Subsequent re-certifications are required at intervals not to exceed 30 days.

Content of Re-certifications

  • The reasons for the continued need for posthospital SNF care.
  • The estimated time the individual will need to remain in the SNF.
  • Plans for home care.
  • If continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for a condition for which he/she had received inpatient hospital services.

Other Important Facts

Regular auditing and education are necessary to ensure that your facility complies with Physicians Certification for Medicare Part A services.

What can a facility do if a certification is missed? Delayed certifications and re-certifications are allowed for an isolated oversight or lapse. However, an explanation of the delay and any other information the SNF considers relevant to explain the delay.

If a beneficiary is discharged from the Part A stay and then resumes covered SNF care within the interruption window, the subsequent resumption would not be considered a new admission. It would not trigger a new certification/recertification schedule. In other words, If the resident has an interrupted stay, the certification schedule would continue upon return.

Most importantly, if the facility uses a form for certifications, be sure the form is filled out completely. Remember, the recertification form or statement must include the all-necessary information listed above to be considered a valid recertification.

A facility may also consider triple check a time to audit certifications for accuracy before a claim is billed. Following these guidelines, a facility will ensure that the Physicians Certification for Medicare Part A services will pass medical review and audits without any problems.

Explore More Posts from MDS Consultants

Reimbursement Concerns

Interim Payment Assessment (IPA) – To do or not to do?

The Patient-Driven Payment Model took effect in October of 2019. Along with this change came the optional IPA. We are now five years into this change and questions still arise on when to complete an IPA. The decision of when to complete lies with the team at the...

Resident Interviews – What are you doing to capture the data?

Effective October 1, 2023, several resident interviews were added to or updated on the MDS. Interview items in Section A and changes to the interviews in Section D, J, and Q have been implemented. Each of the interviews can be a great steppingstone in your path to...

Social Determinants of Health (SDOH) – A Global Initiative Important to Skilled Nursing Providers

The Centers for Medicare & Medicaid Services’ (CMS) Office of Mental Health report CMS Framework for Health Equity 2022 and 2032 states that health equity is defined by the attainment of the highest level of health for all people, where everyone has a fair and...

OSA or PDPM? A State-Level Decision

As of Oct. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) has retired the A0300 Optional State Assessment (OSA) from the federally required MDS 3.0 v1.18.11 that is submitted by nursing facilities. The OSA is now a separate optional MDS assessment...

Achieving Accurate ADLs with the OSA

Section G of the MDS 3.0 was retired October 1, 2023, yet the MDS nurse may still need to use the knowledge of accurately coding ADLs with an assessment called the Optional State Assessment (OSA).  State-Optioned OSA Although the option to choose an OSA from the...

Read more on Toolbox Essentials

New Advanced Beneficiary Notice

Is your facility using the proper ABN form? The Centers for Medicare & Medicaid Services (CMS) recently updated the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131. The new ABN will be mandatory for use on 1/1/2021, but the new form can be...

Covid-19 and Skilled Status

In late June, CMS addressed two issues and posted MDS 3.0 Final Item Sets (V1.17.2).  The two edits were changes to facilitate the calculation of Patient-Driven Payment Model payment codes on OBRA assessments for states that wish to have this calculation performed. ...

Mind Your PHQs

Some skilled nursing facilities (SNFs) are concerned about accurate payment when a resident unexpectedly discharges and the Brief Interview for Mental Status (BIMS) has not yet been completed.However, they should be just as concerned about the PHQ-9. The PHQ-9...

MDS in the Emergency Preparedness Plan

The COVID-19 pandemic has highlighted the need for skilled nursing facilities to have an effective Emergency Preparedness Plan - one that includes sheltering-in-place. The Centers for Medicare and Medicaid Final Rule requires that participating providers have an...

COVID-19 Resources

COVID-19 (coronavirus) Tools In this difficult time, MDS Consultants is here for you with reimbursement guidance and can help with MDS completions when needed. Our team keeps an up-to-date list of links and resources at MDS Expert  COVID-19 (coronavirus) Updates Novel...

MORE from MDS Experts

Section GG Documentation – Questions Still Abound

Section GG remains a popular discussion topic among the Nurse Assessment Coordinator (NAC) and other members of the interdisciplinary team (IDT). Many have questioned their own practices and processes, designed to support coding this section of the MDS. CMS states in...

Social Determinants of Health (SDOH) – A Global Initiative Important to Skilled Nursing Providers

The Centers for Medicare & Medicaid Services’ (CMS) Office of Mental Health report CMS Framework for Health Equity 2022 and 2032 states that health equity is defined by the attainment of the highest level of health for all people, where everyone has a fair and...

Trauma and the MDS – A Sneak Peak

Trauma informed care has become an area of focus for Post Acute Care providers and survey agencies. Organizations are required to provide trauma-informed care that meets “professional standards of practice and accounting for residents’ experiences and preferences in...

New Year….Same MDS Obstacle Course

As we ring in 2024, long term care professionals are still struggling to implement the October 2023 updates to the MDS. CMS is already talking about more changes in 2024, and the anticipation continues to create anxiety amongst PAC members. While the full...

Schizophrenia Diagnosis Audits

On January 18th, 2023, CMS announced they will be conducting off-site audits in nursing homes for assessment accuracy and coding of residents with a diagnosis of Schizophrenia. Along with auditing for appropriate diagnosis, the audits will review appropriate use of...

Webinars & Training

Grow your knowledge with our MDS education

MDS Guides & Forms

Exclusive resources & tools we use every day

Ask an Expert Forum

Members can get 1:1 advice from our MDS experts

Let's Meet in Person

Get more info on our training & conference schedule

News for MDS Experts

Browse our blog & get news alerts on MDS changes

MDS Completion

Get your MDS' done ASAP with short-term, expert help

Remote Floater

Fill gaps on your team when & where you need

Case Mix Index

Improve your complex case mix calculations

MDS System Mgt

Best practices for MDS schedules & workflow

+ More Services

Get help on PDPM, ICD-10, quality, schizoph. audits ++