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SNF Spotlight: CERT top denial reasons for SNF reviews

CMS publishes an annual detailed CERT Report for the improper payment data with details such as:

  • Summary of findings
  • Percent accuracy and improper payment rate
  • Common causes of improper payments (this is broken down into categories and top root causes by service or facility type)
  • Supplemental statistical reporting (this is separated in appendices for service or facility type) 

For the 2024 reporting period, the Medicare FFS improper payment drivers are: Skilled Nursing Facilities, Hospital Outpatient, Inpatient Rehabilitation Facilities, and Hospice. The national projected improper payment amount for SNF services during the 2024 report period was $5.9 billion, resulting in an improper payment rate of 17.2%. The top three categories for SNF errors include insufficient documentation, no reply to medical record request, and other. 

The most common reasons for SNF denials are listed below:

Errors Resolutions
HIPPS Coding Errors does not support MDS reporting of item(s)
  • Documentation that supports: the primary medical condition and active diagnoses reported on the billed MDS
  • Functional Abilities Assessment as reported on the billed MDS
  • Swallowing disorders and nutritional status / type of diet provided as reported on the billed MDS
Missing completely or missing timely certifications / recertifications / delayed certifications
  • Certification / Re-Certification are required to be completed by Physician / Nonphysician Practitioners (NPP)
  • Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable
  • If there was a delayed certification / recertification, submit an explanation for the delay and any medical or other evidence, which the skilled nursing facility considers relevant for purposes of explaining the delay
Missing authenticated physician orders for SNF services, rehabilitative therapies, and/or mechanically altered diets
  • Physician orders for the dates of service billed
  • Physician / NPP documentation that supports the primary medical condition and active diagnoses reported on the billed MDS
Missing physician and/or nursing documentation to support reasonable and necessary SNF services and/or therapy services
  • Initial Evaluation for Therapy Services
  • Physician order for therapy
  • Re-evaluations, when they have been performed
  • Therapy progress reports 
Missing 5-day MDS with ARD in repository
  • MDS validation report documenting the unique identifier with which the billed MDS assessment was submitted and the date of acceptance to the state repository
  • The 5-day assessment and the discharge assessment are required
  • Interim Payment Assessment (IPA) is optional and will be completed when providers determine that the patient has undergone a clinical change that would require a new assessment
Non-response to ADR
  • Documentation was not provided to support the services billed to Medicare

 

References