SNF Physician Certifications for Medical Review

by | Jan 27, 2021 | Tool Box Essentials

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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.

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